Date:

You are being enrolled in Dr. Rupinder Mann RPM Program and are being given a Blood Pressure Monitor IMEI Number:

and you attest that you are not enrolled with any other remote patient monitoring program with another doctor.

The following are the items given to you (please initial against each)

BP Monitor $90USB-C Cable $10Box with User Guide

You hereby take responsibility of the device from loss or damage. In case of a loss or damage to the device or cable, you will reimburse Dr. Mann as per the charges mentioned above

You also acknowledge that you will receive SMS messages on your mobile number:

during this episode of care and herby provide your consent to receive text messages from Dr. Mann or others acting on Dr. Mann behalf.

As part of this consent, you represent and warrant the following:

(1) Dr. Mann or others acting on their behalf may send text messages in various formats and with various contents, including but not limited to, text messages about appointment reminders. 

(2) You are the owner or authorized user of the mobile phone number identified below. You will notify us immediately if you are no longer the owner or authorized user of the mobile phone number identified below. 

(3) You are solely responsible for any message and data charges associated with such text messages. 

(4) You are not enrolled in any other remote patient monitoring program

Patient Printed Name

Date of Birth:

Patient Signature
Clear